1 Office of Consumer Information and Insurance Oversight (OCIIO) OCIIO Office of Oversight Office of Insurance Programs Office of Consumer Support Office of Health Insurance Exchange Division of High Risk Pool Programs Division of Early Retiree Reinsurance Program

2 Insurance Market Reforms

3 Affordable Care Act Included a Variety of Insurance Market Reforms Immediate reforms provide protections for children –Requires insurers to cover pre-existing conditions for children –Permits adults dependents (up to age 26) to remain on parents coverage

4 Affordable Care Act Included a Variety of Insurance Market Reforms In 2014, additional protections for consumers with pre-existing conditions take effect: –Requires insurers to cover pre-existing conditions for adults –Allows premium variation based on age, geographic location, and tobacco use only, effective 2014 –Prohibits annual and lifetime dollar limits on the value of coverage –Establishes health insurance exchanges; premium assistance available for consumers with lower incomes

5 Overview of Pre-Existing Condition Insurance Plan (PCIP)

6 Overview of the Pre-existing Condition Insurance Program (PCIP) Section 1101 of The Affordable Care Act requires that HHS establish a temporary high risk health insurance pool program Provides immediate coverage for individuals with pre-existing conditions until the Health Insurance Exchanges are available in 2014 –Law required establishment within 90 days of enactment

7 ACA Established Basic Eligibility Requirements In order to qualify for PCIP, an individual must: –Be a U.S. citizen or lawfully present in the U.S.; –Have been uninsured for a minimum of 6 months before applying to PCIP; and –Demonstrate inability to access commercial insurance In the federal PCIP, applicants may provide a denial of coverage, offer of coverage with a rider, or offer of coverage at a substantially higher rate* than PCIP Some states use condition lists to establish eligibility; these vary by state *Rate must equal at least 200% of corresponding PCIP rate. Permitted for select applicants.

8 States Chose Whether to Run PCIPs

9 Program Design Allows State Flexibility Existing State Landscape 35 States had established high-risk pools prior to the 2010 federal legislation 10 States had limited open enrollment or no mechanism 5 States had guarantee issue laws Primary goal in establishing PCIP was to allow States the flexibility to leverage existing high risk pools and create programs that reflect the insurance market and needs of their residents.

President signs Affordable Care Act Program Milestones to Date 10 March AprilMayJuneJulyAugustNovember Secretary Sebelius issues letter to states RFP = request for proposals OCIIO reviews state proposals and executes contracts State and federal programs begin accepting enrollment OCIIO issues formal solicitation to states OCIIO issues program regulations Coverage effective for first state-run and federally run programs HHS announces 2011 plan options and premiums OCIIO issues RFP for third party administrator for federal PCIP

2011 Plan Options and Premiums 11 Standard Option Extended Option HSA-eligible Option Premium range (per month; all ages and states) $116 - $626$156 - $842$121 - $650 Medical deductible (per year) $2,000$1,000$2,500 Drug deductible (per year) $500$250Incl. in medical Office Visit Copay (per visit) $25 Drug Copay (per prescription) $4, $40, $80$4, $30, $60 Annual out-of-pocket limit$5,950 NOTE: All deductible and copayment amounts are for in-network benefits. In 2011, consumers in the federally run PCIPs will be able to choose among three plans with different premiums and cost-sharing requirements Summary of 2011 Plan Options

Behavioral Health Benefits Enrollees in federally run PCIPs receive the same behavioral health coverage as federal employees 12 Professional Services Diagnostic and treatment services outlined in an approved plan of care Individual or group therapy Medication management Psychological, diagnostic, and laboratory tests Inpatient and Outpatient Care Diagnostic and treatment services outlined in an approved plan of care Includes care delivered in inpatient residential treatment facilities Emergency Services Plan covers 80 percent of costs related to emergency care NOTE: Not a comprehensive list of benefits. Some benefits require pre-certification.

13 PCIP Moving Forward Focus on Outreach –Pursuing a targeted outreach and enrollment strategy –Partnering with external groups to educate consumers –Generating earned media –Working with insurers, agents, and brokers to increase awareness about PCIP Finalizing Interim Final Regulations –Comments were due September 28, 2010

14 Questions and Answers

15 For more information on the Pre-existing Condition Insurance Plan, please visit Richard Popper